Cost of Early Cholecystectomy in Mild Gallstone Pancreatitis

By IAN KRATZKE, MD

In the Journal of the American College of Surgeons, Isbell et al published results from a secondary analysis of the Gallstone PANC Trial (Gallstone Pancreatitis: Admission vs Normal Cholecystectomy) (J Am Coll Surg 2021;233[4]:517525.e1). That trial was a single-center, randomized controlled trial evaluating the 30-day hospital length of stay (LOS) among patients with mild gallstone pancreatitis who receive early (≤24 hours of admission) cholecystectomy versus cholecystectomy after clinical resolution of pancreatitis.

This trial found early cholecystectomy was associated with a shorter LOS but an increase in non‒life-threatening complications. It should be noted, however, that patients with a high likelihood of choledocholithiasis (bilirubin >1.8 mg/dL; bile duct >6 mm) were excluded from the study because they were more likely to receive preoperative endoscopic retrograde cholangiopancreatography (ERCP).

This retrospective cost analysis used patient data from the Gallstone PANC Trial and collected additional data from the hospital accounting system related to follow-up clinic or emergency department visits, as well as 90-day readmission and discharge data. Costs were adjusted to 2020 U.S. dollars, and analyses were considered from a healthcare system perspective using frequentist and Bayesian multivariate regression models.

There were 49 patients in the early cholecystectomy group and 48 patients in the control arm. The authors found that within the 90-day period, patients treated with early cholecystectomy had a significantly lower rate of preoperative ERCP (0 vs. 6; P=0.01) and had a mean difference of 0.96 fewer days of hospitalization (95% CI, ‒1.91 to 0.00; P=0.05). These results were calculated to be an average reduction in cost by 8% and translated to $1,216 in savings per patient. The probability that patients receiving early cholecystectomy would incur reduced costs was found to be 81%. Four patients across the groups were found to have complications, all non–life-threatening.

This study adds to the findings of the Gallstone PANC Trial by evaluating the hospital LOS up to 90 days post-discharge and including an evaluation of total costs within this same period stratified by the timing of cholecystectomy. Although the difference in LOS was found to be only approximately one day, given the incidence of patients presenting with mild gallstone pancreatitis, this reduction in time and resources could translate to millions of dollars annually in the United States, as well as a faster return to normal activity for patients. However, the small sample size from a single center of a specific subset of patients limits the generalizability of this study. As such, additional data may be needed to capture the incidence of complications with early cholecystectomy compared with the benefit of reducing hospital LOS. Regardless, this study speaks to the need for surgeons to consider the severity of pancreatitis when determining the timing of cholecystectomy.

Open, Laparoscopic or Robotic for Inguinal Hernia Repair?

By IAN KRATZKE, MD

In the Annals of Surgery, Glasgow et al published a cost analysis that compared the value of three approaches to inguinal hernia repair (2021;274[4]:572-580). This was a single-center, retrospective study of patients undergoing unilateral inguinal hernia repair with an open, a laparoscopic or a robotic technique. Current Procedural Terminology (CPT) codes were used to identify procedures performed by 14 surgeons, all of whom were experienced in the surgical approach used.

Value was defined as quality divided by cost, in which quality (based on recurrence rate) was assumed to be equivalent for each repair, and cost was calculated as both fixed (basic OR equipment [e.g., surgical instruments, laparoscopic systems and robotic systems use and maintenance]) and variable (“materials,” which included supplies used perioperatively; “providers,” which included surgeon and anesthesiologist time; and “overhead,” which included cost per minute of OR time and factors in support staff labor). Cost data were compared among approaches using linear modeling normalized to the open approach. The study involved 100 consecutive patients undergoing each type of operation.

The authors found that for fixed costs, the laparoscopic inguinal hernia repair was 1.03 times more expensive than an open repair, and the robotic repair was 3.18 times more costly than open. For variable costs, laparoscopic repair was not significantly higher than the open approach (1.02 times; P=0.78), but robotic repair was 2.11 times higher than open (P<0.001) and 2.06 times higher than laparoscopic. Within these costs, material costs for laparoscopic repair were higher (1.5 times; P<0.001) than open repair, but overhead costs were lower (0.81 times; P=0.003) than for an open repair, due to the shorter mean calculated operating time of laparoscopic repair compared with open (82 vs. 107 minutes). All domains of variable costs for robotic repair were higher than for the other approaches.

Taking all costs and considering the revenues associated with each approach, the authors found the laparoscopic inguinal hernia repair had a gross margin 4% higher than the open approach, while

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